Volume 29, Issue 133 (March & April 2021)                   J Adv Med Biomed Res 2021, 29(133): 68-73 | Back to browse issues page


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Shahi F, Emami S A H, Shirazi M, Mokhtari S, Moghimi M, Gohari S, et al . Assessing Physicians’ Performance when Telling the Truth to Patients Diagnosed with Cancer. J Adv Med Biomed Res 2021; 29 (133) :68-73
URL: http://journal.zums.ac.ir/article-1-6068-en.html
1- Dept. of Hematology & Medical Oncology, Cancer institute, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran.
2- Dept. of Clinical Sciences and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.
3- Dept. of Neonatology,School of Medicine, Mousavi Hospital, Zanjan University of Medical Sciences, Zanjan, Iran.
4- Dept. of Hematology & Medical Oncology,School of Medicine, Vali-e-Asr Hospital, Zanjan University of Medical Sciences, Zanjan, Iran.
5- School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
6- Dept. of Internal Medicine, Vali-e-Asr Hospital, Faculty of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
7- Dept. of Hematology & Medical Oncology, Cancer institute, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran. , rezamansouri93@yahoo.com
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✅ Guidelines which are introducing the most harmless methods for delivering bad news with minimal negative effects on the patients’ mental health can be helpful for the medical staff, so that they can perform this important task with less stress and minimum complications for the patients.


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Introduction
 

The ability to tell the truth to patients, especially when delivering bad news, is an important factor in a proper doctor-patient relationship. Since the expression or concealment of truth, in addition to moral issues, could also cause legal difficulties, it is important to adopt an appropriate approach to this matter, especially in diseases such as cancer (1).
Over the past thirty years, the trend of changes in social interactions has affected the doctor-patient relationship and led to improved adherence to patient’s rights. Accordingly, patients are entitled to know the facts about their illness and doctors, instead of making decisions for patients based on their knowledge and expediency, are required to provide information to the patients and help them make decisions. Thus, developing a proper doctor-patient relationship is crucial for patients’ understanding of their health status, their adaptation to the disease and its complications, and their commitment to the therapies recommended by the medical team (2-4). Reports have indicated that most cancer patients prefer to be informed about their illness (5). Doctors are also more willing to inform their patients about the cancer diagnosis (6).
It seems that the probability and manner of telling the truth to a cancer patient depends on certain factors, including stage of cancer, cultural conditions of each community, as well as the patient’s economic condition, intelligence, and education. The physician’s working experience and stage of the disease also affect the physician’s opinion (1). Despite the growing awareness of patients and the vital importance of a proper doctor-patient relationship and the way bad news is delivered, most physicians and specialists have not received a structured training in this regard yet (7). In recent years, many efforts have been made to improve the communication skills of medical staff, especially with regard to delivering bad news. Some countries have compiled guidelines in this regard and provided them to physicians and medical staff (8-10). One of such guidelines to present distressing information in an organized manner to patients and families is the SPIKES protocol (setting, patient perception, invitation, knowledge, emotions, summary and strategy) (11). Since there is no structured guideline in this regard in Iran, the current study was designed according to the SPIKES protocol.


 

Materials and Methods

Study design, participants, and variables
A total of 12 hematologists and oncologists from Imam Khomeini and Shariati Hospitals in Tehran, Iran were included in this descriptive cross-sectional study in 2017. Data were collected by a questionnaire for the physicians. The test was designed and conducted in Persian based on SPIKES model; also, the reliability and validity of the questionnaire have been confirmed in other studies (12, 13). The questionnaire included six statements: preparing the patient, ending the discussion and summarizing the content, effective communication, using the word ‘cancer’, preparing the environment, and the patient's right to the information. The relationship between age, gender, the least and most time allotted to deliver the bad news to the patient, the number of patients who have been given bad news in the last three months, the educational records, and the time of delivering cancer diagnosis to the patient by the doctor were all examined with the average score of doctors for each statement. In addition, demographic data including gender, age, patients’ records, and physicians’ medical education were examined. The study was approved by the Research Ethics Committee of Tehran University of Medical Sciences [code: IR.TUMS.IKHC.REC. 1396. 3411] and informed consent was obtained from all the participants.
 
Data Analysis
Quantitative data were expressed as mean and standard deviation and qualitative data were expressed as frequency or relative frequency. Independent sample t-test was used to investigate the relationship between quantitative and qualitative variables with two specific values. One-way ANOVA was employed to investigate the relationship between the quantitative and qualitative variables with more than two values. Linear regression was used to examine the relationship between the quantitative variables.

 
 
Results

Demographic Data
Out of 12 physicians (faculty members) who participated in this study, 10 were male (83.3%) and 2 were female (16.7%). The average age of the physicians was 51.08±6.73 years old (males: 52.60±1.75 vs. females: 43.50±6.50). Statistically, there was no significant difference between the age of the male and female participants (P=0.17).

Patients’ Visit Records Data
According to the data, 2 (16.6%), 3 (25%), and 7 (58.3%) physicians had informed less than 5, 5 to 10, and more than 10 patients of their cancer diagnosis in the past three months, respectively. The average for least and most time allotted by the physicians to report the bad news was 12.50±7.53 and 30.83±13.79 minutes, respectively.

Educational Records of Physicians
Six physicians (50.0%) had no educational background in medical ethics. Meanwhile, three physicians (25.0%) had completed the medical ethics course as a part of their curriculum and 3 physicians (25.0%) had completed it as extended education.

Analysis of Study Results
Relationship Between Gender and Average Score of Physicians for Each Statement
According to Table 1, there was no significant relationship between the gender of physicians and the score given by physicians for each statement (P>0.05). Since there were only two female physicians in the present study, these results could not be generalized.

Relationship Between Age and Average Score of Physicians for Each Statement
The results of the linear regression showed no significant relationship between the mean score of physicians per statement and age of the physicians (P>0.05) (Table 1).
 
Relationship Between the Time Allotted to Deliver the Bad News to the Patients and the Average Score of Physicians for Each Statement
Except for ending the discussion and summarizing as well as using the word ‘cancer’ when breaking the bad news to the patient, the results of linear regression represented no significant relationship between the least and most time allotted to deliver the bad news to the patients and any other statements (P>0.05) (Table 1).

Relationship Between The Number of Patients Who Have Been Given Bad News in the Last Three Months and the Average Score of Physicians in Relation to Each Statement
The results of the one-way ANOVA demonstrated no significant relationship between any of the statements and the number of patients who were given bad news in the past three months (P>0.05) (Table 1).

Relationship Between Educational Background and the Average Score of Physicians for Each Statement
The relationship between educational background and the average score given to each statement was assessed by one-way ANOVA test. A significant relationship was found between having medical ethics training and the average score of the physician in relation to preparing the patient (P=0.013) and ending the discussion and summarizing (P=0.013) statements. Additionally, the results of the data analysis showed a significant relationship between having previous training in delivering bad news and the average score of physicians in relation to preparing the patient (P=0.031), ending the discussion and summarizing (P=0.00), and the patient's right to be informed of their cancer diagnosis (P=0.02) statements (Table 1).
 
Relationship Between the Time of Delivering the Cancer Diagnosis to the Patient by the Physician and the Average Score of Physicians in Relation to Each Statement
The one-way ANOVA test showed a significant relationship between the time of delivering the news to the patient and ending the discussion and summarizing (P=0.049), patient's right to know about their cancer diagnosis (P=0.036), and effective communication (P=0.037) statements (Table 1).

 
Table 1. The relationship between different factors associated with delivering cancer diagnosis to the patient by the physician and the average score of physicians in relation to each statement

Variable Preparing the patient Ending the discussion and summarizing Effective communication Using the word ‘cancer’ Preparing the environment The patient’s right to know about their cancer diagnosis
Gender
(Mean±SD)
Male 4.00±0.166 4.48±0.146 4.13±0.200 2.50±0.182 3.80±0.239 3.75±0.153
Female 4.62±0.125 4.70±0.100 4.665±0.333 2.75±0.250 4.16±0.166 3.25±0.250
P value 0.140 0.535 0.291 0.576 0.527 0.203
Age
(Mean±SD)
Less than 50 4.20±0.284 4.63±0.158 4.55±0.164 2.66±0.247 4.16±0.319 3.75±0.214
More than 50 4.00±0.144 4.40±0.193 3.68±0.267 2.41±0.200 3.55±0.204 3.58±0.200
P value 0.871 0.929 0.581 0.820 0.515 0.944
Least amount of time
(Mean±SD)
Less than 5 min 3.39±0.56 4.30±0.35 4.80±0.37 2.12±0.18 3.17±0.34 3.50±0.71
5 to 10 min 3.87±0.12 4.73±0.47 3.33±0.16 2.25±0.89 3.15±0.91 3.25±0.38
More than 10 min 4.29±0.25 4.73±0.71 3.70±0.84 2.50±0.91 4.16±0.33 3.91±0.81
P value 0.084 0.048 0.087 0.012 0.180 0.705
Most amount of time
(Mean±SD)
10 to 20 min 3.93±0.25 4.30±0.17 4.08±0.15 2.15±0.12 3.75±0.15 3.50±0.20
More than 20 min 4.18±0.61 4.63±0.19 4.29±0.26 2.75±0.18 3.91±0.30 3.75±0.18
P value 0.258 0.043 0.222 0.052 0.327 0.704
Number of patients in the last three months
(Mean±SD)
Less than 5 4.00±0.500 4.50±0.100 4.16±0.166 2.50±0.250 3.83±0.166 4.16±0.166
5 to 10 4.58±0.220 4.86±0.133 4.44±0.111 3.16±0.166 4.55±0.444 3.58±0.200
More than 10 3.95±0.218 4.30±0.198 4.16±0.362 2.33±0.210 3.56±0.267 2.50±0.250
P value 0.384 0.289 0.930 0.122 0.262 0.133
Training in medical ethics
(Mean±SD)
 
Yes 4.39±0.162 4.89±0.068 4.42±0.119 2.92±0.130 4.03±0.214 3.71±0.214
No 3.21±0.183 3.67±0.101 3.93±0.385 2.34±0.135 3.57±0.235 3.60±0.187
P value 0.013 0.013 0.079 0.541 0.899 0.260
Training in delivering bad news
(Mean±SD)
Yes 4.50±0.144 4.83±0.080 4.40±0.113 2.85±0.129 4.03±0.227 3.83±0.210
No 3.70±0.150 4.20±0.146 3.94±0.315 2.53±0.083 3.68±0.200 3.50±0.182
P value 0.000 0.012 0.128 0.510 0.112 0.017
Time of delivering the bad news P value 0.441 0.049 0.037 0.742 0.036 0.434

 

 

Discussion

The present study showed that, despite having work experience, training experience for delivering bad news, is important. Almost all the physicians (11 out of 12 physicians) expressed the need for a structured guideline on how to deliver bad news to patients. This result is consistent with the study conducted by Biazar et al. in which 83% of participants expressed the need for educational courses for breaking bad news (14). Some countries have already compiled guidelines in this regard and provided them to physicians and medical staff (8-10).
In this study, no significant relationship was observed between different statements and age and gender. Due to the small number of male and female physicians, it is not possible to rely on the statistical tests regarding the age difference between the male and female physicians. Shah Shahsanai et al. reported no significant association between physicians’ gender and their opinion on telling the truth to patients with cancer in early stages, while there was a significant relationship between male and female physicians' views on telling the truth to the patients with advanced cancer; 54% of females and only 10% of males agreed to tell the truth to the patients with cancer in advanced stages (1).
The results of the present study showed that the physicians who passed medical ethic courses had relatively higher scores. These results are consistent with the findings of two clinical trials carried out by Baghdari et al. and Managheb et al. (15, 16).
Additionally, the results of this study showed a significant relationship between the time of informing the patients about their cancer diagnosis and summarizing and ending the discussion (P=0.049), the patients’ right to know about their illness (P=0.036), and effective communication (P=0.037) statements. Physicians who believed in delivering bad news to the patient as soon as they were diagnosed with cancer scored higher on these statements. It seems that the physician’s attitude towards telling the truth to the patient is closely related to their performance in delivering bad news. Therefore, education and training in subjects like understanding patients’ rights and also medical ethics courses can play a major role in improving the physicians’ performance when delivering bad news.
Although in this study providing a calm, private, and confidential environment as well as allotting more time to delivering the bad news meant higher scores, physicians could not dedicate more time to delivering bad news and preparing patients, so that they can come into terms with the news more easily since proper and specific physical space and facilities are lacking in the hospitals.


 

Conclusion

Additionally, other factors that may contribute to poor performance in delivering bad news were the use of the word ‘cancer’ and not introducing the patient to psychological counseling. Therefore, more research on how physicians tend to deliver bad news is necessary in order to explain and discover its various aspects based on the experiences of patients, their families, and medical staff. To sum up, guidelines which are introducing the most harmless methods to delivering bad news with minimal negative effects on patients’ mental health can be helpful for the medical staff, so that they can fulfill this critical task with less stress and minimum complications for patients.


 

Data availability

The raw data supporting the findings of this study are available in case of any request.

 

Acknowledgements

To use and publish the scientific data obtained by the questionnaire, a written consent form was obtained from the author of the article who designed the form.
We thank all the physicians who participated in and contributed to the study.


 

Ethical considerations

Ethical issues (Including plagiarism, informed consent, misconduct, data fabrication and/or falsification, double publication and/or submission, redundancy, etc.) have been completely observed by the authors.

 

Funding and support

This research resulted from an independent research without receiving any financial support.

 

Conflicts of Interest

Authors declared no conflict of interests.

Type of Study: Original Article | Subject: Clinical medicine
Received: 2020/06/15 | Accepted: 2020/08/16 | Published: 2020/12/2

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